02100090 CITY OF CUPF.KHN0 -�
BUILDING DIVISION PERMIT %CONTRACTOR INFORMATION:,-
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Bulfi2l&-1A9r5FrsLAS ONDAS WY JUST WATER HEATERS INC PFRMrrN(02100090
OwlrgT Wr:DARRYL A AND DOROTHY A rR1764 NATIONAL AVE APPLICATIT`91 11r�2002
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ONE: (510) 293-9901 SANITARY NO, CONTROL NO.
ARCHI'IECf/ENGINEER: BUILDING PERMIT INFO
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00 LICENSECONrRACTOR'SDCCLARAI'ION
<�c�i Ihemhy affirm that l am licensed under provisionsof Chapmr 9(Commencing REPLACE WATER J e1C�f tion
y00 with SectionTop)of Division 3 of NC Business and Professions Cuba.and my license is
n in full fexcand effect.
License Cuss Lie 0
y_w Doc Comanc,
ARCDT cTS DECLARATION
as 1 understand my plans shall he used a puhlic records
spy
uai3 u.t Licensed Professional
in❑i—`�< OWNER.BUILDER DECLARATION
as <E 1 hereby affirm that 1 me exempt form the Contractors License Law far the $800
�a600 following reason.ISecuon 7031.5.Business and Profea'ions Codc:Any city of county
x%� which requires a pmmit to construct,alter,improve,demolish,or repair any nromome
1O prion its issuance,also requires the applicantforsuch permino file asigned statement
��S< shat he is licensed pCement n the provisions Of the Contmcha's license Law(Cluster,9 Valuation
(commencing with Section LMk)of Division 3 of the Rushrom and Professions Code)or
of $ that he is o exempt Orrefors and the bais for the alleged exemption.Any violation of
Section 7031.5 by any applicant for a permit subjects the applicant to a Civil penalty of
not man than five hundred dollars(M). 506 NGAS TEST ccupancyType
❑1.se;owner Of the property,or my employees with wages as their solectne,crmation.
will do the work,and the straaom is not intended or offered for sale(Sec.7W,Business
and Professions Code:The Contractor's License Law does not apply to an owner of equlre nSpections
property who builds or improves thereon,and who does such work himself or through his
own employees,provided that such improvements are not intended or offered for sale.If,
builder ,Nebuilding mimprovement isSold within me ildofimprovefrpuowner-
builder will have tM bother of proving that he did nw MiIJ or improve for purpose of
sale.).
❑1,as owner of the Sec.pro,scrq,,B sines and contracting with licensed contractus i- /
cense La d project(pec.o W4,Business and property
who
ds or
no Contractor's nd v/
Li-
cense Law rites not apply to anwith
owner Of property who sed parr impmvice thereon,end
whocontractsLaw. for such projects with o comednnr(s)licensed pursuant m the Cnnlmctur's
License Law.
❑ lam exempt under Sea ,BAPCfnr this mason
Owner Data
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under penalty of perjury one of the following declarations:
I have and will maintain a Certificate of Consent to self-insum for Worker's Compere
satinr.as provided for by Section 3710 of the Labor Code,for the performance of the
work for which Nis permit is issued.
❑1 ban and will maintain Worker's Compensation Insurance,as mquired by Section
37M of the Iybor Code,for the performance of the work for which this permit is issued.
My Worker's Compensation Insurance artier and Policy number am:
Carie,: Policy N..:--
CERTIFICATE
o.: _CERTIFICATE OF EN EMPTION FROM WOR KERS'
COM PENSATION INSURANCE
(This section need not M completed if the permit is for one hundred dollars ISIOut
nr less.)
1 cenify that in the performance of the work for which this permit is issued,I shall not
employ any Nrum in any manner so As to hecrme Subject o the Workers'Compensation
Laws of California.Date
Applicant
NOTICE TO APPLICANT:IC after making this Certificate of Exemption,you should
become suhject to the Worker's Compensation previsions of the Labor Code,you must
O O forthwith comply with such provisions or this Permit shall N deemed revoked.
z CONSTRUCTION LENDING AG ENCY
I hereby affirm Nat there is a Conswntal lending agency l Or performance of
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the work fur which this permit is issucd(SecJly37,Civ.C.)
:0 Q lender's Name
h Lender's Address
U 0 1 cenify Nat 1 have read this application and sum that the above information is
D. F Correct.I agree tocomply with all city and county ordinances and sum laws relating to
0 building construction,and hereby authono:repiesenutives Of this city to enter upon the
Ya show mentioned property for inspection purposes.
C. (We)agree to save,indemnify and keep harmless the City of Cupertino against
h liabilities,judgments,Costs and expenses which may in any way accede against said City
U in consequence of the granting of this Fermi t.
'^ APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON POINT Issued by: Date
SOURCE REGULATIONS.
Re-roofs
Signature ofApplicartaContractor Data
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the eFCupert or!mune opal Cg e,Chapter
r 9.1 Or handle harallous material
as defined by the Cupertino Municipal Code,CAapter 9.12,and the flcalth and Safety
c„de.Scoinr 25532(a)7 All roofs shall be inspected prior to an roofing material beim
❑Yea ❑No P P � Y g g installed.
Will the el,i Or future building ocCupum use cyoPmeto or devices which If a roof is installed without first obtaining an inspection,I agree to remove
not h crodu s it Conmminanks as defined by the Bay Are.Air Quality Management all new materials for inspection.
District?
❑Yes ❑No
1 have read the hwardous materials requirements under Chapter 6.95 of the Ouif tar
at.l lcalth&Safety Cad.Sections 25.515,25533 and 25534.1 understand Wm lithe Iwllding -
does not cuotolly bave u tenant,that it is my resptmeihil ity to notify the Occupant of the
requirements which most he mel prion,,kweptm,,f.Cenifm.teof 0.cupnncg Signature Of Applicant Date
Owner at aamadxed agent Date All roof coverings to be Class "B”Or better